Form SFN52477 "ACH Authorization (Direct Deposit)" - North Dakota

What Is Form SFN52477?

This is a legal form that was released by the North Dakota Department of Commerce - a government authority operating within North Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2005;
  • The latest edition provided by the North Dakota Department of Commerce;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form SFN52477 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Commerce.

ADVERTISEMENT
ADVERTISEMENT

Download Form SFN52477 "ACH Authorization (Direct Deposit)" - North Dakota

Download PDF

Fill PDF online

Rate (4.5 / 5) 48 votes
ACH AUTHORIZATION (Direct Deposit)
NORTH DAKOTA DEPARTMENT OF COMMERCE
SFN 52477 (10-2005)
VENDOR INFORMATION
Vendor Name
Address
City
State
Zip Code
Contact Name (Please print or type)
Telephone Number
E-Mail Address
EIN/SSN
Type of Change (please check one of the following):
New
Revised
Bank Change
Authorized Signature Change
Type of Business (please check one of the following):
Nonprofit or Government Entity
Corporation
Individual or Sole Proprietorship
Other (Please Specify)
Partnership
BANK INFORMATION
Financial Institution Name
Type of Account
Is this an interest-bearing account?
Checking
No
Yes
Financial Institution Routing Number
Vendor Account Number
Program (Please check one)
CDBG
HOME Funds
ESGP
Americorps
Other
This ACH form will authorize all payments for this program to be automatically deposited into the financial institution listed
above.
Signature of Authorized Vendor
Printed Name of Authorized Vendor
Date
Signature of Authorized Vendor
Printed Name of Authorized Vendor
Date
I certify that the signatures above are of the Individuals Authorized to Draw for the Request for Funds. (The Certifying Official
cannot be one of the above signatures.)
Signature of Certifying Official (Grantee)
Date
STATE AGENCIES REQUESTING VENDOR INFORMATION
Send completed form to:
Vendor Registry Use Only
Department of Commerce
Vendor Number
Approved By DOC
PO Box 2057
Bismarck, ND 58502-2057
Location Name
Approved By
Telephone: 701-328-5300
Fax: 701-328-5320
Date
DOC will forward original signed form to ND Vendor Regsitry Office.
ACH AUTHORIZATION (Direct Deposit)
NORTH DAKOTA DEPARTMENT OF COMMERCE
SFN 52477 (10-2005)
VENDOR INFORMATION
Vendor Name
Address
City
State
Zip Code
Contact Name (Please print or type)
Telephone Number
E-Mail Address
EIN/SSN
Type of Change (please check one of the following):
New
Revised
Bank Change
Authorized Signature Change
Type of Business (please check one of the following):
Nonprofit or Government Entity
Corporation
Individual or Sole Proprietorship
Other (Please Specify)
Partnership
BANK INFORMATION
Financial Institution Name
Type of Account
Is this an interest-bearing account?
Checking
No
Yes
Financial Institution Routing Number
Vendor Account Number
Program (Please check one)
CDBG
HOME Funds
ESGP
Americorps
Other
This ACH form will authorize all payments for this program to be automatically deposited into the financial institution listed
above.
Signature of Authorized Vendor
Printed Name of Authorized Vendor
Date
Signature of Authorized Vendor
Printed Name of Authorized Vendor
Date
I certify that the signatures above are of the Individuals Authorized to Draw for the Request for Funds. (The Certifying Official
cannot be one of the above signatures.)
Signature of Certifying Official (Grantee)
Date
STATE AGENCIES REQUESTING VENDOR INFORMATION
Send completed form to:
Vendor Registry Use Only
Department of Commerce
Vendor Number
Approved By DOC
PO Box 2057
Bismarck, ND 58502-2057
Location Name
Approved By
Telephone: 701-328-5300
Fax: 701-328-5320
Date
DOC will forward original signed form to ND Vendor Regsitry Office.